CFPC CAC Palliative Care cheat sheet

Palliative care is an approach improving quality of life for patients and families facing life-limiting illness, through prevention and relief of suffering by early identification, impeccable assessment, and treatment of pain and other physical, psychosocial, and spiritual problems.

Hospice/palliative designation typically requires a prognosis-based criterion; in Canada, expected survival of months rather than years (commonly framed as prognosis of about 3 months or less for some programs) plus a stated goal of comfort care and informed consent for the designation.

Total pain model: suffering has physical, psychological, social, and spiritual/existential dimensions; each must be screened because treating only nociception leaves refractory distress.

Routine screening tools: Edmonton Symptom Assessment System (ESAS-r) for nine symptoms scored 0-10; Palliative Performance Scale (PPS) for functional status in 10% decrements; CAGE or similar for substance use history before opioid escalation.

Prognostic tools in advanced disease: PPS score, Palliative Prognostic Score (PaP), and the 'surprise question' (would I be surprised if this patient died within 12 months) - all are aids, not deterministic.

Goals-of-care conversation elements: assess decision-making capacity, identify substitute decision-maker, explore illness understanding and values, disclose prognosis in chunks with 'ask-tell-ask', recommend a plan, document and share.

Delirium at end of life is common (up to 80-90% in final weeks); screen with the Confusion Assessment Method, search for reversible causes (opioids, anticholinergics, hypercalcemia, urinary retention, constipation, dehydration) before sedating.

Grief and bereavement: normal grief is not a disorder; prolonged grief disorder requires persistent, disabling yearning or preoccupation beyond 12 months in adults (6 months in children/adolescents) after the death.

Last-days care: stop non-essential medications (statins, antihypertensives, anticoagulants, hypoglycemics, vitamins), continue analgesics, anxiolytics, and antisecretory agents, and provide anticipatory prescribing for pain, dyspnea, secretions, and agitation.

Cancer pain ladder: step 1 non-opioid (acetaminophen/NSAID); step 2 weak opioid (codeine, tramadol); step 3 strong opioid (morphine, oxycodone, hydromorphone, fentanyl, methadone); add adjuvants at any step for neuropathic pain (gabapentinoids, tricyclics, SNRIs, corticosteroids).

Opioid-naive starting doses (oral, immediate release): morphine 5-10 mg q4h, oxycodone 2.5-5 mg q4h, hydromorphone 0.5-1 mg q4h; also prescribe a breakthrough dose of roughly 10% of total daily dose given q1h as needed.

Equianalgesic oral ratios: morphine 10 mg = oxycodone 5 mg = hydromorphone 1-2 mg; when rotating between opioids, reduce the calculated equianalgesic dose by 25-50% for incomplete cross-tolerance, then re-titrate.

Fentanyl transdermal is for opioid-tolerant patients only; oral morphine 60 mg/day (or equivalent) is the usual threshold; patches are changed every 72 hours and are inappropriate for acute or unstable pain because of slow onset.

Opioid adverse effects: constipation is universal and does not tachyphylax (prescribe a stimulant laxative prophylactically); nausea, sedation, and pruritus usually resolve in days; respiratory depression is rare with titration and is preceded by increasing sedation.

Dyspnea: low-dose opioids (e.g., morphine 2.5-5 mg oral or 1-2 mg subcutaneous in opioid-naive patients) relieve air hunger; supplemental oxygen helps only if hypoxemic; fan and cool airflow help regardless of oxygen saturation.

Nausea: choose antiemetic by mechanism - metoclopramide or domperidone for gastric stasis, haloperidol or methotrimeprazine for chemical/metabolic causes, ondansetron for serotonin-mediated causes, dexamethasone for raised intracranial pressure or bowel obstruction.

Malignant bowel obstruction: trial of dexamethasone (e.g., 4-8 mg/day) plus metoclopramide if incomplete; if complete obstruction, stop prokinetics and use antisecretory agents (octreotide, glycopyrrolate, scopolamine) plus analgesia; nasogastric tube only if vomiting is intractable.

Terminal secretions ('death rattle'): reposition and explain to family; if distressing, use anticholinergics such as glycopyrrolate, scopolamine, or atropine drops; suctioning gives brief benefit and may cause discomfort.

Palliative sedation for refractory symptoms: reserve for existential or physical distress unrelieved by aggressive measures, obtain informed consent where possible, use proportional (not deep) sedation first, and document intent to relieve suffering, never to hasten death.

Capacity assessment is task- and time-specific: patient must understand the relevant information, appreciate the consequences, reason about options, and express a choice; a diagnosis of dementia or delirium does not automatically negate capacity.

Substitute decision-making hierarchy in most Canadian jurisdictions prioritizes a capable appointed attorney/representative, then a spouse or partner, then other relatives, then the public guardian; decisions must follow the patient's prior capable wishes, then best interests.

Advance care planning differs from advance directives: planning is an ongoing process of values discussions; directives (living wills, goals-of-care forms) are written documents that may or may not be legally binding by jurisdiction.

Medical Assistance in Dying (MAiD, Canada): requires a capable adult, grievous and irremediable condition, informed consent, and two independent assessments; track 2 (non-terminal) adds a 90-day assessment period, and final consent must be reaffirmed immediately before provision unless waived under specific legal conditions.

Breaking bad news framework (SPIKES): Setting, Perception, Invitation, Knowledge, Emotions/empathy, Strategy and summary; respond to emotion before giving more information.

Conflict resolution: distinguish disagreement about facts, goals, and values; use a family conference with the patient present when possible, name the emotion, reframe around what the patient would want, and involve ethics consultation for persistent intractable conflict.

Cultural safety and humility: ask about preferred decision-making roles (individual versus family-centered), language needs (trained interpreter, not a child), religious rituals at death, and practices around truth-telling about prognosis.

Withdrawal of life-sustaining treatment is ethically equivalent to withholding it; the process requires a documented rationale, symptom management plan, and clear communication that the intent is to allow natural death.

Self-care and burnout: clinicians should recognize moral distress, use peer debriefing after difficult deaths, and know that compassion satisfaction is protective; institutional wellness resources are part of quality care.